Platinum Partner Member Form

As an NRHA Platinum Partner, you receive an Industry Organizational Membership, which includes two full voting memberships and thirteen individual non-voting memberships.

1. The primary member should be the main contact for all marketing efforts and the main point of contact for the partnership.

2. The secondary member should be the CEO or the decision maker for the rural healthcare focus.

3. We encourage you to include at least one member of your sales or business development team.

4. Primary and secondary members will have voting rights on NRHA matters.

5. All partner members are automatically enrolled in the Hospitals & Health Systems Constituency Group.

6. All partner members may choose two additional CGs to be involved in if they wish.

7. Additional optional CGs are listed below or go to our CG website page to learn more.

Company Name

Company Website

Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Member Name (Manages NRHA Membership)

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

Secondary Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#3 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#4 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#5 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#6 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#7 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#8 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#9 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#10 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#11 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#12 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

#13 Member Name

First NameLast Name

Title

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Constituency Groups (Choose up to two additional)

Hospitals & Health Systems

NRHA Platinum Partner Member Form